Early diagnosis of testicular torsion will save a ball…
An 8-year-old presents with right testicular pain. What are your differential diagnoses and why?
This is the topic we asked Camille to talk about at DFTB17 in Brisbane.
| Peak Age | Frequency | Comments | |
| Torsion appendix testis | Prepubertal (9-11 years) | 60% | |
| Torsion testis | Neonatal; puberty | 30% | |
| Epididymo-orchitis | Infancy | < 10% | Look for underlying urinary tract abnormality |
| Idiopathic Scrotal Oedema | 5-6 years | < 10% | Testes are non-tender |
| Trauma | It MAY be a red herring |
The boy’s age is the biggest clue to the diagnosis.
Although testicular torsion is commoner in pubertal boys and neonates, it can strike at any age.
Even though torsion of appendix testis may be the commonest cause of an acute scrotum in the paediatric age group, testicular torsion should still be the #1 differential, as it is important not to miss it.
I am always asking myself: “Why is it NOT testicular torsion?” If I can’t answer that satisfactorily, that boy is going to theatre.
Torsion of appendix testis
Why is it commoner in older boys?
Torsion of the appendix testis is generally at the age when the boy is about to hit puberty – the oestrogen surge that precedes testosterone will stimulate the mesonephric (aka Mullerian aka “female”) remnant that is the appendix testis (aka hydatid of Morgagni), which engorges and twists on its narrow stalk.
How can you tell if it is testicular torsion?
| Testicular torsion | Testiscular torsion |
| Onset usually slower / more insidious – longer history of pain (eg on/off for 1-2 days) | Onset usually quite sudden |
| May have associated vomiting | |
| Comfortable if sitting still, with legs apart(usually looks fairly happy playing on iPad or iPhone, until we approach) | More commonly in pain all the time |
| Testis may be riding higher or horizontal lie. | Tender all over testis |
| Tender over upper pole The rest of testis may be non-tender | Testis may be riding higher, or horizontal lie. |
Torsion of appendix testis presenting late (i.e. after 2-3 days) may be associated with significant hydrocele that will obliterate all the distinguishing features listed above and make it almost impossible to distinguish from testicular torsion.[
How do you treat a torted testicular appendage?
You usually should seek diagnostic confirmation with the Surgical Registrar.
If you cannot convince yourself that it is NOT testicular torsion, they need an urgent referral for scrotal exploration.
Testicular torsion
Always consider the diagnosis.
Symptoms as above
Clinical signs can be subtle or obvious.
Trap for young players
Beware intermittent torsion – there may be no signs as the testis may have de-torted. Boys with recurrent pain that sounds like torsion should be referred to a surgeon for consideration of non-urgent scrotal exploration, especially if there is horizontal lie!
Beware undescended testes – they are at higher risk of torsion. The patient will have an empty scrotum and a painful lump in the groin…
Perinatal torsion
How is it different to the usual torsion?
The torsion usually happens in the perinatal period (i.e. can be antenatal or early postnatal period).
It is usually extravaginal torsion – i.e. the tunica vaginalis is not yet adherent to the surrounding scrotal tissue.
It is classically described as PAINLESS.
The testis is usually dead by the time of diagnosis/operation.
The other side is at risk of metachronous torsion (timing is variable).
The aim is to save the other ball, as the affected one is usually unsalvageable.
How do you recognise perinatal torsion?
We usually get referrals from the Nursery, but parents occasionally bring their neonate to Emergency with one large purple hemiscrotum.
Look for asymmetry of the testes/hemiscrotum. The hemiscrotum is enlarged or indurated but not always tender.
Idiopathic scrotal oedema
This can be almost thought of as cellulitis of the scrotum.
As the name suggests, most of the time, we do not know the cause. Sometimes, there is a small scratch or insect bite in the scrotal area. It tends to affect pre-schoolers.
It starts as a small spot and then involves the whole hemiscrotum – from the base of the penis to the perineum, and even laterally to the inguinal area, and sometimes both hemi-scrotum.
Importantly, the testes are NOT tender.
The scrotal skin itself is indurated, oedematous, red and tender.
If you can reach the testis through unaffected skin (sometimes from the non-affected scrotum), you will find that it is not tender and can safely exclude torsion.
Epididymo-orchitis
This would be amongst the last on my list of differential diagnoses and not one I would confer easily.
It tends to affect the very young or very old paediatric patient.
In the middle age range (2–12 years), the vas is narrow, and no semen is produced, so there are fewer instances of epididymitis.
In older post-pubertal boys, epididymitis can occur due to the reflux of secretions up a wide vas. Sexual contact also needs to be taken into consideration.
In infants with epididymitis, urinary tract anomalies need to be excluded, e.g. ureteric anomalies. I would confirm the diagnosis with a urine culture and obtain a renal tract ultrasound in this age group.
References
Gutti JM, Murphy JP. Current management of the acute scrotum. Seminars of Pediatric Surgery, 2007; 16(1): 58-63
